Management for Erectile Dysfunction and Premature ejaculation

1. Psychotherapy and sex therapy
   Many men suffer from performance anxiety or situational ED. This may stemmed from certain bad experiences in the past or a lack of experience.  Some men develop a fear towards sexual activity and leading to avoidance.  This avoidance behaviour will lead to further anxiety and physical de-conditioning of penile blood flow if ignored.  Erectile dysfunction can have further impact on relationship/marriage, self-confidence, and ultimately may even lead to depression and suicides.  In many incidences, brief session with a psychologist/sex therapist may be enough to resolve the problem and restore normal life.  This should be regarded as the first line treatment in sexual dysfunctions.
   
   
2. Marriage and relationship counseling
   Some men suffering from erectile dysfunction or other sexual dysfunction due to marriage disharmony, extramarital relationship or sometimes just poor communication and sexual skills. Relationship and marriage counseling aiming to restore couple relationship and/or to find solutions to the couples’ relationship problems.  This therapy usually requires both couples to attend and with more intensive sessions with the therapist in order to find the final solution.
   
   
3. Lifestyle modification
   Lifestyle factors such as smoking, alcohol, drug abuse, lack of sleep is all contributing factors to erectile dysfunction. These should be modified as part of the overall management plan.
   
   
4. Oral Medications
   Medications such Viagra, Cialis and Levitra (PDE5-inhibitors) provides effective treatment to many men who have erectile dysfunction. However, in some men, oral medications may not work initially.  The failure rate on average is about 50-30%.  This may due to individual’s physical conditions/diseases, other concurrent medications, incorrect method/timing of taking the medicine, lack of sex drive/stimulation and many other reasons.  In these cases, the causes of failure need to be further assessed and, often, after some adjustments and education, they will work.  However, sometimes even after adjustment, other forms of treatment may be required.  Usually the side effects of oral medications are mild, including headache, hot flushes, nausea, blue vision (Viagra) and in rare cases may lead to blindness.  PDE5 inhibitors must not be used by patients taking nitrite for ischemic heart disease.
   
   
5. Intracavernous Injection Therapy
   Before the popularity oral medication, intracavernous therapy was the main stream treatment for ED. It is still used by many who did not have sufficient erection after oral medications.  This therapy requires self-injection of medicine into the penis to may the blood vessels to dilate.  The injection has been made easier with an auto-injector.  The success rate of having an adequate erection is over 95%.  Some studies have also show after using Intracavernous Injection Therapy, some people may return to normal function.  However, this requires regular usage on a weekly basis and a lot of persistence is needed.  The complications of injection therapy include priapism (a prolong erection lasting over 4 hours), infection, bruising and plaque/fibrosis formation at the injection site.  But all these complications can be minimized by following straight instructions.
   
   
6. Hormonal Replacement Therapy
   Testosterone deficiency is increasingly being known as a cause of ED. Low testosterone level leading to low sex drive, poor response to sexual stimulation and reduced vascular response to vasodilatation.  To confirm, low testosterone level requires blood test to examine the level of free testosterone in the blood.  If testosterone deficiency is confirmed, testosterone replacement is helpful in restoring normal function.  In some men, a combined use of testosterone replacement and PDE5 inhibitor will increase the effectiveness of oral medication.  Testosterone comes in oral (daily) and injection form (about once every 3-6 weeks).  The side effect of testosterone replacement including increased prostate and liver problem but there are newer form of testosterone medication had show no effect on prostate and liver after 10 years.
   
   
7. Growth Hormone
   Growth hormone has been increasingly used in anti-aging therapy. A decline in sexual function due to aging has been associated with a reduction in the level of growth hormone.  In some cases, growth hormone may be used in conjunction with PDE5 inhibitors to improve its effectiveness and restore the overall physical condition of the patients.
   
   
8. Vacuum Device
   Some men would like to use non-medical treatment; vacuum device may be an option. It requires a suction device either operating automatically or manually.  In all cases, a constrictor ring is required to stop blood being drained out from the penis.